Healthcare Provider Details

I. General information

NPI: 1003205121
Provider Name (Legal Business Name): CRYSTA FLETCHER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTA LOVIN

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3284 NORTH BEND RD SUITE 314
CINCINNATI OH
45239-7688
US

IV. Provider business mailing address

4760 MADISON RD
CINCINNATI OH
45227-1426
US

V. Phone/Fax

Practice location:
  • Phone: 513-481-2432
  • Fax: 513-662-2432
Mailing address:
  • Phone: 513-861-0035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI1000115
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: